92
I SOME ASPECTS OF COMMUNITY MEDICINE
IN NIGERIA
Some aspects of community medicine in Nigeria Dr P. C. Osuhor, MB, BS, DPH Lecturer, Department of Community Medicine, Ahmadu Bello University, Zaria, Nigeria
TROPICAL DOCTOR,
1977, 7, 92-95
A community may be defined as a set of households within a delimited geographical area, where the residents show a substantial degree of social interaction and have a sense of common membership and togetherness. Modern medical practice has led to the realization that the injurious effects of disease on man are due to many factors, not least of which are the social conditions of particular communities. Factors such as the environment, knowledge, attitudes, beliefs, culture, customs, and the component of the working place form the complex of social conditions. The reaction of a community to sickness and health depends largely on the nurturing processes of its members from infancy to old age. A deeper understanding of these concepts is a prerequisite for more effective medical care. All members of the medical team in the community must acquire and utilize such knowledge. Comprehensive health care, which is the totality of all aspects of medical practice, both curative and preventive, is affected in Nigeria by the shortage of personnel, equipment, drugs, and finance. Medicine in the community studies the total health of the individual in the home, family, community, and environment and uses this knowledge for the application of the principles of delivery of comprehensive health care. Thus the community is viewed as a whole and the total population is the patient. This paper describes some practical experience in the teaching and delivery of comprehensive health care by the Department of Community Medicine of Ahmadu Bello University, Zaria. ORGANIZATION OF HEALTH SERVICES IN NIGERIA
Scientific medical practice began in Nigeria probably about 500 years ago with the advent of Portuguese traders (Schram 1971). The explorers, traders, colonial army and administrative officers and missionaries arrived later and established some forms of health institutions primarily for themselves. The present Nigerian medical services grew out of these early military and missionary efforts. The following bodies now provide modern health services in Nigeria:
Tropical Doctor, April I977 I. Government - state and national, through the various ministries of health; 2. Local authorities, through the various local health authorities (mainly dispensaries and mobile clinics in the rural areas); 3. Voluntary agencies; 4. Armed forces, through the Armed Forces Medical Services; 5. Private practitioners; 6. Industries, through various industrial health schemes; 7. Universities and their teaching hospitals. The bulk of the health care (about 80%) of various communities is undertaken by the government, the voluntary agencies and the local health authorities. The Armed Forces and industries provide health services for young healthy adults and their families, while the private practitioners, mainly in the urban areas, are patronized by the more affluent sections of the communities. The teaching hospitals tend to be selective in their clientele through the various departments and units through referrals to the appropriate consultants. There were 2,683 registered medical practitioners in Nigeria in 1972. Half of them were non-Nigerians (Dada 1972). At the moment, there are about 3,000 doctors for about 70 million people giving a ratio of one doctor per 23,000 population. The ratio for other health manpower is not much better. There is a high concentration of the available personnel and facilities in the six medical schools and the bigger general hospitals which are largely situated in the urban areas. If these points are considered separately for urban and rural population, it will be seen that the rural areas are grossly neglected.
COMMUNITY SOCIO-MEDICAL PROBLEMS
Gradually, various Nigerian communities and the government are becoming increasingly aware of their health and medical problems. But due to limited resources, including finance, the provision of health institutions is not fast enough. Where they are present, they are not properly and fully utilized in certain communities. For example, the majority of the Nigerian population are of the Moslem faith, who have not yet quite accepted modern medicine. The females marry at puberty or around 13 years with all the attendant problems of early marriage and pregnancy. Ablution after toilet is widely practised among the Moslems and is bound to increase the chances of faeco-oral infections, especially where the standards of hygiene are unsatisfactory. The nomadic life of a significant number of this population does not contribute towards maximum utilization of medical facilities. Other points that may adversely affect the health of Nigerian communities are the distances involved,
Tropical Doctor, April I977 mode of transport, and the economics of hospital attendance. People are willing to trek or cycle to seek medical help but the gradient of attendances falls off as the distances to these health facilities increase (King 1970; Inga 1973). There is marked seasonal variation in these attendances among the rural farming communities, depending on the planting and harvest seasons (minimum attendance due to farm work) and the dry months (maximum attendance due to post-harvest leisure) (Yuwadi 1973). It is estimated that about 60% of all hospital cases in Nigeria are controllable and/or preventable (Mohammed 1973). This means that if there is properly planned community health care, most of the diseases that reach the costly hospitals would be prevented or controlled. Some of these diseases include gastroenteritis, pneumonia, measles, meningitis, tuberculosis, cholera, and malaria. Community comprehensive medical practice is therefore a necessity in order to establish a balance between costs on the one hand and maximum good medical care on the other. THE PRACTICE OF MEDICINE IN THE COMMUNITY I. The MedicalPractitioner: In most general hospitals in Nigeria, the medical officer is also the medical officer of health for the division or district. It is therefore important that he must have the expertise to manage and extend his services beyond the hospital walls to the greater advantage of his community. He must also be exposed to, the tools of medical practice in the community While in 'the medical school (Challenor 1972). At the Medical School of Ahmadu Bello University (ABU), Zaria, community medicine is taught for the five undergraduate years. This was recommended in the Jessop Report (Jessop 1968). In the more traditional subjects like medicine and surgery, the teaching programme is so arranged-that by the time the doctor qualifies, he is able to look at his patient as a whole, in his family unit, community, and within his socialand working environment (Fig. I). The sessional programme in community medicine is as folloWs:' " -, Year I - Statistical methods and vital statistics, medical sociology,.demography, social anthropology> and human ecologyare introduced. " ," Year II - Environmental health and sanitation, water supply, nutrition, and health education are the subjects taught. .. Year III - Epidemiology is the main subject. Control of communicable diseases in man, disease patterns in the community, and more areas in medical sociology are covered.
SOME ASPECTS OF COMMUNITY MEDICINE IN NIGERIA
I 93
Year IV - Maternal and child health (MeH) and social paediatrics are the main subjects. Two weeksof rural posting in community medicine is arranged for students in groups of 10 to 15 at a time in ABU Rural Teaching Hospital, Malumfashi, 80 miles north of the university town of Zaria. During this posting, emphasis is placed on the practice of comprehensive medical care - that is, integrated programmes embodying both curative and preventive medical care are arranged. Year V - The practice of community medicine, health management and planning, organization and administration of health services, community dentistry, and community diagnosis of diseases and sickness are taught. There is now a Faculty final year posting for seven weeksto Malumfashi for the practice of community health care. The final year projects on selected community orientated topics are allocated to students early in the session. These projects carry 20% of the total marks in the final MBBS examination in community medicine. Visits to factories, health institutions, allied fields, for example, the Nigerian Institute for Trypanosomiasis Research (NITR) and veterinary departments, waterworks, markets, and compounds are arranged periodically between Year II and Year V. It will be seen that on qualifying, the
Fig. I. The healthteam- a medical student,a lecturer andan auxiliaryexplain thepurpose of the MeH clinic to a village headin MalumfashiDistrict, NorthernNigeria.
94
I SOME ASPECTS OF COMMUNITY MEDICINE IN NIGERIA
Tropical Doctor, April I977
young doctor is more able to harness all his knowledge in the effectivemanagement of his patient either in the hospital or in the community. 2. The Dispensary Assistant: The Institute of Health, Alunadu Bello University, Zaria, through the Medical Auxiliary Training School (MATS), Kaduna, is also responsible for the training of the dispensary assistants. The minimum entry requirement is primary seven certificate and the course lasts for two years. The students are mostly sponsored by the various local health authorities in the Northern States of Nigeria. Simple curative and preventive measures against various communicable diseases are taught. They are now posted in small groups to Malumfashi where they form part of the comprehensive health team. After training, the students return to their States and are usualIy posted to the rural areas. Refresher courses are periodically arranged for field workers also (Figs. 2, 3). 3. The Health Inspectors and Health Assistants: The School of Hygiene, Kano, a part of the Institute of Health, ABU, Zaria, trains health inspectors and health assistants. The minimum entry requirement for the health inspector's course is the West African School Certificate (WASC) or equivalent, while that of the health assistant is primary seven. The courses last three and two years respectively with practical training by attachments to various local health authorities. half way through the courses and also
Malumfashi posting in small groups in their final year. The emphasis is on control of communicable diseases, environmental health, and sanitation. After qualifying, the working environment is both urban andruraI. The Institute of Health, Alunadu Bello University, Zaria, recognizes the fact that different types of auxiliaries must be trained locally and utilized in the delivery of basic health services. The three main reasons for such a policy are conservation of scarce professional skills, development of multiple sides of these services, and the relative cheapness and quickness in training and employing them (Shehu 1975). At its various MCH clinics, auxiliaries have been trained locallyand assigned the following duties: urine tests for sugar and protein, weighing patients and recording these weights in appropriate charts; offering nutrition advice and simple health education and distributing pre-packed malarial chemoprophylaxis and haematinics. They also act as interpreters to the clinic doctors. It would be seen that at one stage in the training of the health team, medical students, nurses, dispensary assistants, health inspectors and assistants, and other auxiliaries are brought together by the Department of Community Medicine so that each category's problems are appreciated and the spirit of team work is introduced long before they qualify (Fig. 4). Other staff employed by the Institute of Health,
Fig. 2. Dispensary assistant, issuing pre-packed drugs topregnant mothers at theruralM CH clinic.
Fig. 3. A ruralMCH clinic in Malum/ashi District. Workiscarried outboth in thehut and under the tree.
Tropical Doctor, April I977 Zaria, for medical practice in the community include the community nurses, health sisters/visitors, medical social workers, dieticians, and medical records personnel. Their duties are well known and need no separate comments here. With the shortage and uneven distribution of health and medical manpower and facilities between the rural and urban areas of Nigeria, the available resources should be made to serve more patients than the various health institutions are doing at the moment. Team work is therefore needed in this context with the doctor as the leader of the health and medical team. Referral systems must operate so that optimal use is made of the available facilities and personnel at various appropriate levels in the health systems. The various health agencies should plan and co-ordinate their preventive, control, and eradication programmes jointly both on State and National levels. As of now, health planning and priorities have been fragmented and haphazard even in different divisions or districts of the same State. The ministries and departments mentioned before should plan and co-ordinate their
SOME ASPECTS OF COMMUNITY MEDICINE IN NIGERIA
I 95
work with health bodies. Thus finance, equipment, and personnel may be adequately utilized. CONCLUSION
Within the community, disease processes undergo their natural history. The population makes efforts to control, eradicate, prevent, and treat these disease processes. Each community has its structure, organization, culture, traditions, and social patterns. We should therefore organize our fight against these disease processes in different societies in Nigeria, bearing in mind these socialpatterns. Communicable disease, inadequate and poor refuse disposal and water supply systems are still major problems. By giving our health team the necessary training through comprehensive health approach, they would help the various communities to the very best of their abilities, knowledge, and experience even with our limited and scarce resources. Community medicine has been dubbed by some as the medicine of poverty and rural areas. However, community medicine could be studied and practised wherever there are communities, for example among the Texas millionaires or among the most underdeveloped societies in the world. The emphasis may shift from communicable to non-communicable diseasesbut the tools are still the same. REFERENCES
Fig. 4. The auxiliaryhealthteam,locally trainedin thefield by the authorand Miss A. Deleon, a nutritionist. Fromleft to right:dispensary assistant; in charge of weighing infants; clinic recorder; laboratory assistant; clinic recorder; in charge of anthropometric measurements; in charge of weighing pregnant women and otherchildren.
Challenor, B. D., et al. (1972). Ann. intern. Med., 76, 689. Dada, B. A. A. (1972). Current Health Manpower and Facilities in Nigeria and Statistical Guide-lines for their Development during the 1970-79 Decade. Lagos State Government: Ministry of Health and Social Welfare, Medical Statistics. Inga, D. F. (1973). An analysis of the distribution of the locality from which patients come to Samaru Clinic, Zaria; Final year Community Medicine Project, Department of Community Medicine, Ahmadu Bello University, Zaria. Jessop, W. J. E. (1968). Assistance to the Medical School, Ahmadu Bello University, Zaria, Northern Nigeria. World Health Organization (Unpublished report). King, M. (1970). The Organization of Health Services; in Medical Care in Developing Countries. London: Oxford University Press. Mohammed, W. S. (1973). Analysis of available vital statistics of Malumfashi Galadima District. Final year medical student project, Department of Community Medicine, Ahmadu Bello University, Zaria. Schram, R. (1971). A History of the Nigerian Health Services. Ibadan University Press. Shehu, U. (1975). General trends in health activities in Nigeria: The roles of the members of the health team in the provision of Health Services: Institute of Health Newsletter, Ahmadu Bello University, Zaria, Vol. I, No. 12, Dec. 1975, 17-21. Yuwadi, J. S. B. (1973). Analysis of ante-natal clinic attendance in Zaria Hospital, 1971. Final year medical student project, Department of Community Medicine, Ahmadu Bello University, Zaria.
I SOME ASPECTS OF COMMUNITY MEDICINE
IN NIGERIA
Some aspects of community medicine in Nigeria Dr P. C. Osuhor, MB, BS, DPH Lecturer, Department of Community Medicine, Ahmadu Bello University, Zaria, Nigeria
TROPICAL DOCTOR,
1977, 7, 92-95
A community may be defined as a set of households within a delimited geographical area, where the residents show a substantial degree of social interaction and have a sense of common membership and togetherness. Modern medical practice has led to the realization that the injurious effects of disease on man are due to many factors, not least of which are the social conditions of particular communities. Factors such as the environment, knowledge, attitudes, beliefs, culture, customs, and the component of the working place form the complex of social conditions. The reaction of a community to sickness and health depends largely on the nurturing processes of its members from infancy to old age. A deeper understanding of these concepts is a prerequisite for more effective medical care. All members of the medical team in the community must acquire and utilize such knowledge. Comprehensive health care, which is the totality of all aspects of medical practice, both curative and preventive, is affected in Nigeria by the shortage of personnel, equipment, drugs, and finance. Medicine in the community studies the total health of the individual in the home, family, community, and environment and uses this knowledge for the application of the principles of delivery of comprehensive health care. Thus the community is viewed as a whole and the total population is the patient. This paper describes some practical experience in the teaching and delivery of comprehensive health care by the Department of Community Medicine of Ahmadu Bello University, Zaria. ORGANIZATION OF HEALTH SERVICES IN NIGERIA
Scientific medical practice began in Nigeria probably about 500 years ago with the advent of Portuguese traders (Schram 1971). The explorers, traders, colonial army and administrative officers and missionaries arrived later and established some forms of health institutions primarily for themselves. The present Nigerian medical services grew out of these early military and missionary efforts. The following bodies now provide modern health services in Nigeria:
Tropical Doctor, April I977 I. Government - state and national, through the various ministries of health; 2. Local authorities, through the various local health authorities (mainly dispensaries and mobile clinics in the rural areas); 3. Voluntary agencies; 4. Armed forces, through the Armed Forces Medical Services; 5. Private practitioners; 6. Industries, through various industrial health schemes; 7. Universities and their teaching hospitals. The bulk of the health care (about 80%) of various communities is undertaken by the government, the voluntary agencies and the local health authorities. The Armed Forces and industries provide health services for young healthy adults and their families, while the private practitioners, mainly in the urban areas, are patronized by the more affluent sections of the communities. The teaching hospitals tend to be selective in their clientele through the various departments and units through referrals to the appropriate consultants. There were 2,683 registered medical practitioners in Nigeria in 1972. Half of them were non-Nigerians (Dada 1972). At the moment, there are about 3,000 doctors for about 70 million people giving a ratio of one doctor per 23,000 population. The ratio for other health manpower is not much better. There is a high concentration of the available personnel and facilities in the six medical schools and the bigger general hospitals which are largely situated in the urban areas. If these points are considered separately for urban and rural population, it will be seen that the rural areas are grossly neglected.
COMMUNITY SOCIO-MEDICAL PROBLEMS
Gradually, various Nigerian communities and the government are becoming increasingly aware of their health and medical problems. But due to limited resources, including finance, the provision of health institutions is not fast enough. Where they are present, they are not properly and fully utilized in certain communities. For example, the majority of the Nigerian population are of the Moslem faith, who have not yet quite accepted modern medicine. The females marry at puberty or around 13 years with all the attendant problems of early marriage and pregnancy. Ablution after toilet is widely practised among the Moslems and is bound to increase the chances of faeco-oral infections, especially where the standards of hygiene are unsatisfactory. The nomadic life of a significant number of this population does not contribute towards maximum utilization of medical facilities. Other points that may adversely affect the health of Nigerian communities are the distances involved,
Tropical Doctor, April I977 mode of transport, and the economics of hospital attendance. People are willing to trek or cycle to seek medical help but the gradient of attendances falls off as the distances to these health facilities increase (King 1970; Inga 1973). There is marked seasonal variation in these attendances among the rural farming communities, depending on the planting and harvest seasons (minimum attendance due to farm work) and the dry months (maximum attendance due to post-harvest leisure) (Yuwadi 1973). It is estimated that about 60% of all hospital cases in Nigeria are controllable and/or preventable (Mohammed 1973). This means that if there is properly planned community health care, most of the diseases that reach the costly hospitals would be prevented or controlled. Some of these diseases include gastroenteritis, pneumonia, measles, meningitis, tuberculosis, cholera, and malaria. Community comprehensive medical practice is therefore a necessity in order to establish a balance between costs on the one hand and maximum good medical care on the other. THE PRACTICE OF MEDICINE IN THE COMMUNITY I. The MedicalPractitioner: In most general hospitals in Nigeria, the medical officer is also the medical officer of health for the division or district. It is therefore important that he must have the expertise to manage and extend his services beyond the hospital walls to the greater advantage of his community. He must also be exposed to, the tools of medical practice in the community While in 'the medical school (Challenor 1972). At the Medical School of Ahmadu Bello University (ABU), Zaria, community medicine is taught for the five undergraduate years. This was recommended in the Jessop Report (Jessop 1968). In the more traditional subjects like medicine and surgery, the teaching programme is so arranged-that by the time the doctor qualifies, he is able to look at his patient as a whole, in his family unit, community, and within his socialand working environment (Fig. I). The sessional programme in community medicine is as folloWs:' " -, Year I - Statistical methods and vital statistics, medical sociology,.demography, social anthropology> and human ecologyare introduced. " ," Year II - Environmental health and sanitation, water supply, nutrition, and health education are the subjects taught. .. Year III - Epidemiology is the main subject. Control of communicable diseases in man, disease patterns in the community, and more areas in medical sociology are covered.
SOME ASPECTS OF COMMUNITY MEDICINE IN NIGERIA
I 93
Year IV - Maternal and child health (MeH) and social paediatrics are the main subjects. Two weeksof rural posting in community medicine is arranged for students in groups of 10 to 15 at a time in ABU Rural Teaching Hospital, Malumfashi, 80 miles north of the university town of Zaria. During this posting, emphasis is placed on the practice of comprehensive medical care - that is, integrated programmes embodying both curative and preventive medical care are arranged. Year V - The practice of community medicine, health management and planning, organization and administration of health services, community dentistry, and community diagnosis of diseases and sickness are taught. There is now a Faculty final year posting for seven weeksto Malumfashi for the practice of community health care. The final year projects on selected community orientated topics are allocated to students early in the session. These projects carry 20% of the total marks in the final MBBS examination in community medicine. Visits to factories, health institutions, allied fields, for example, the Nigerian Institute for Trypanosomiasis Research (NITR) and veterinary departments, waterworks, markets, and compounds are arranged periodically between Year II and Year V. It will be seen that on qualifying, the
Fig. I. The healthteam- a medical student,a lecturer andan auxiliaryexplain thepurpose of the MeH clinic to a village headin MalumfashiDistrict, NorthernNigeria.
94
I SOME ASPECTS OF COMMUNITY MEDICINE IN NIGERIA
Tropical Doctor, April I977
young doctor is more able to harness all his knowledge in the effectivemanagement of his patient either in the hospital or in the community. 2. The Dispensary Assistant: The Institute of Health, Alunadu Bello University, Zaria, through the Medical Auxiliary Training School (MATS), Kaduna, is also responsible for the training of the dispensary assistants. The minimum entry requirement is primary seven certificate and the course lasts for two years. The students are mostly sponsored by the various local health authorities in the Northern States of Nigeria. Simple curative and preventive measures against various communicable diseases are taught. They are now posted in small groups to Malumfashi where they form part of the comprehensive health team. After training, the students return to their States and are usualIy posted to the rural areas. Refresher courses are periodically arranged for field workers also (Figs. 2, 3). 3. The Health Inspectors and Health Assistants: The School of Hygiene, Kano, a part of the Institute of Health, ABU, Zaria, trains health inspectors and health assistants. The minimum entry requirement for the health inspector's course is the West African School Certificate (WASC) or equivalent, while that of the health assistant is primary seven. The courses last three and two years respectively with practical training by attachments to various local health authorities. half way through the courses and also
Malumfashi posting in small groups in their final year. The emphasis is on control of communicable diseases, environmental health, and sanitation. After qualifying, the working environment is both urban andruraI. The Institute of Health, Alunadu Bello University, Zaria, recognizes the fact that different types of auxiliaries must be trained locally and utilized in the delivery of basic health services. The three main reasons for such a policy are conservation of scarce professional skills, development of multiple sides of these services, and the relative cheapness and quickness in training and employing them (Shehu 1975). At its various MCH clinics, auxiliaries have been trained locallyand assigned the following duties: urine tests for sugar and protein, weighing patients and recording these weights in appropriate charts; offering nutrition advice and simple health education and distributing pre-packed malarial chemoprophylaxis and haematinics. They also act as interpreters to the clinic doctors. It would be seen that at one stage in the training of the health team, medical students, nurses, dispensary assistants, health inspectors and assistants, and other auxiliaries are brought together by the Department of Community Medicine so that each category's problems are appreciated and the spirit of team work is introduced long before they qualify (Fig. 4). Other staff employed by the Institute of Health,
Fig. 2. Dispensary assistant, issuing pre-packed drugs topregnant mothers at theruralM CH clinic.
Fig. 3. A ruralMCH clinic in Malum/ashi District. Workiscarried outboth in thehut and under the tree.
Tropical Doctor, April I977 Zaria, for medical practice in the community include the community nurses, health sisters/visitors, medical social workers, dieticians, and medical records personnel. Their duties are well known and need no separate comments here. With the shortage and uneven distribution of health and medical manpower and facilities between the rural and urban areas of Nigeria, the available resources should be made to serve more patients than the various health institutions are doing at the moment. Team work is therefore needed in this context with the doctor as the leader of the health and medical team. Referral systems must operate so that optimal use is made of the available facilities and personnel at various appropriate levels in the health systems. The various health agencies should plan and co-ordinate their preventive, control, and eradication programmes jointly both on State and National levels. As of now, health planning and priorities have been fragmented and haphazard even in different divisions or districts of the same State. The ministries and departments mentioned before should plan and co-ordinate their
SOME ASPECTS OF COMMUNITY MEDICINE IN NIGERIA
I 95
work with health bodies. Thus finance, equipment, and personnel may be adequately utilized. CONCLUSION
Within the community, disease processes undergo their natural history. The population makes efforts to control, eradicate, prevent, and treat these disease processes. Each community has its structure, organization, culture, traditions, and social patterns. We should therefore organize our fight against these disease processes in different societies in Nigeria, bearing in mind these socialpatterns. Communicable disease, inadequate and poor refuse disposal and water supply systems are still major problems. By giving our health team the necessary training through comprehensive health approach, they would help the various communities to the very best of their abilities, knowledge, and experience even with our limited and scarce resources. Community medicine has been dubbed by some as the medicine of poverty and rural areas. However, community medicine could be studied and practised wherever there are communities, for example among the Texas millionaires or among the most underdeveloped societies in the world. The emphasis may shift from communicable to non-communicable diseasesbut the tools are still the same. REFERENCES
Fig. 4. The auxiliaryhealthteam,locally trainedin thefield by the authorand Miss A. Deleon, a nutritionist. Fromleft to right:dispensary assistant; in charge of weighing infants; clinic recorder; laboratory assistant; clinic recorder; in charge of anthropometric measurements; in charge of weighing pregnant women and otherchildren.
Challenor, B. D., et al. (1972). Ann. intern. Med., 76, 689. Dada, B. A. A. (1972). Current Health Manpower and Facilities in Nigeria and Statistical Guide-lines for their Development during the 1970-79 Decade. Lagos State Government: Ministry of Health and Social Welfare, Medical Statistics. Inga, D. F. (1973). An analysis of the distribution of the locality from which patients come to Samaru Clinic, Zaria; Final year Community Medicine Project, Department of Community Medicine, Ahmadu Bello University, Zaria. Jessop, W. J. E. (1968). Assistance to the Medical School, Ahmadu Bello University, Zaria, Northern Nigeria. World Health Organization (Unpublished report). King, M. (1970). The Organization of Health Services; in Medical Care in Developing Countries. London: Oxford University Press. Mohammed, W. S. (1973). Analysis of available vital statistics of Malumfashi Galadima District. Final year medical student project, Department of Community Medicine, Ahmadu Bello University, Zaria. Schram, R. (1971). A History of the Nigerian Health Services. Ibadan University Press. Shehu, U. (1975). General trends in health activities in Nigeria: The roles of the members of the health team in the provision of Health Services: Institute of Health Newsletter, Ahmadu Bello University, Zaria, Vol. I, No. 12, Dec. 1975, 17-21. Yuwadi, J. S. B. (1973). Analysis of ante-natal clinic attendance in Zaria Hospital, 1971. Final year medical student project, Department of Community Medicine, Ahmadu Bello University, Zaria.
